Pain Questionnaire. Center for Interventional Pain 1000 Health Center Drive, Suite 106 Mattoon, IL

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1 Center for Interventional Pain 1000 Health Center Drive, Suite 106 Mattoon, IL Pain Questionnaire Date First name Last name Middle initial Date of birth Sex Male Female Height Weight Referring physician Primary care physician Where is your pain located? (Please shade the painful areas on the diagram below.) How would you describe your pain? Burning Numbness Sharp Aching Throbbing Shooting Page 1 of 5

2 Which statement best describes your pain? Always present, always the same intensity Always present, intensity varies Pain comes and goes Does your pain interrupt your sleep? Not at all 1 to 2 times per night 2 to 3 times per night More than 3 times per night What makes your pain feel worse? Coughing, sneezing Sitting Standing Lying down Physical activity When did you first notice your pain? Under what circumstances did your pain begin? No reason, it just began Accident at work Accident at home Motor vehicle accident Following surgery Following illness If your pain resulted from an injury, describe how it happened. What makes your pain feel better? Relaxation Sitting Heat Standing Medicines Lying down Nothing makes me feel better Describe any work restrictions or reductions due to your physical condition. Circle a number from 0 to 10 to indicate how strong your pain is at its worst Circle a number from 0 to 10 to indicate how strong your pain is on the average. Has your pain limited any of the following activities? Climbing stairs Getting in and out of bed Getting up and down from a chair Balance Feeding/grooming/bathing Page 2 of 5

3 Since your pain began, has it: Increased Decreased Stayed the same Have you been hospitalized for your pain? No Yes (if yes, where?) Have you had any of the following treatments for your pain? Epidural injection yes no If yes, did it help? Trigger point injections yes no If yes, did it help? Nerve blocks yes no If yes, did it help? Physical therapy yes no If yes, did it help? Chiropractic treatment yes no If yes, did it help? Acupuncture yes no If yes, did it help? TENS yes no If yes, did it help? Pain medications yes no If yes, did it help? List pain medications that your have tried before: Are you allergic to any medications? yes no If yes, what are the names of the medications?: Do you smoke? yes no If yes, how many packs per day? Do you drink alcohol? yes no If yes, approximately how many drinks per week? Do you do any street drugs? yes no If yes, what kind of drugs? Does anyone in your family have chronic pain or disability? yes no If yes, please explain: Do you have any other health problems? High blood pressure Diabetes Heart disease Stroke Seizures Kidney disease Liver disease Lung disease Thyroid disease Arthritis Peptic ulcer/reflux Cancer Frequent headaches Psychiatric diseases Page 3 of 5

4 Have you had previous surgeries? none yes (please list) Please list all medications you are taking with the dosage and frequency. Include over-the-counter medications, like Tylenol, Advil, herbal, etc. Medication Dosage Frequency This questionnaire was completed by: Patient Date Parent/guardian Date Other Date Page 4 of 5

5 Do you have any of the following symptoms? Numbness Weakness Muscle spasms Skin discoloration Coldness Increase in sweating Yes No If yes, where: Yes No If yes, describe: Bowel problems Bladder problems Recent weight gain Decreased appetite Fever Sore throat Hoarseness of voice Difficulty swallowing Chest pain Swelling of legs Irregular heart beat Difficulty lying flat on your back Wheezing Shortness of breath at rest or exertion Coughing Diarrhea Nausea and vomiting Joint swelling Seizures Difficulty sleeping Mood swings Depression Skin rash (Women) Are you pregnant or trying to get pregnant? Excessive bleeding Do you bleed more than expected? Has a dentist told you that you bleed more than usual? Have you had trouble with bleeding after surgery?

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